The notion of medical futility has quantitative and qualitative roots that offer a practical approach to its definition and application. Applying these traditions to contemporary medical practice, we propose that when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile. Unlike decision analysis, which defines the expected gain from a treatment by the joint product of probability of success and utility of outcome, our definition of futility treats probability and utility as independent thresholds. Futility should be distinguished from such concepts as theoretical impossibility, such expressions as "uncommon" or "rare," and emotional terms like "hopelessness." In judging futility, physicians must distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which appreciably improves the person as a whole. Treatment that fails to provide the latter, whether or not it achieves the former, is "futile". Although exceptions and cautions should be borne in mind, we submit that physicians can judge a treatment to be futile and are entitled to withhold a procedure on this basis. In these cases, physicians should act in concert with other health care professionals, but need not obtain consent from patients or family members.

High social value is fundamental to justifying these studies

Six years ago, we proposed a patient benefit-centered definition of medical futility that included both quantitative and qualitative components. We distinguished between an effect of a treatment that is limited to some part of a patient's body and a benefit that improves the patient as a whole. The quantitative portion of our definition stipulated that physicians should regard a treatment as futile if empirical data show that the treatment has less than a 1 in 100 chance of benefiting the patient. The qualitative portion of our definition stipulated that if a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, physicians should consider the treatment futile. In this paper, we clarify and modify our original proposal and respond to the following major criticisms: 1) Medical futility is simply an attempt to increase the power of the physician over the patient and to repeal recent hard-gained advances in patient autonomy; 2) no professional or societal consensus has been achieved about the definition of futility; 3) futility is a value-laden determination, the usurpation of which by medicine is inappropriate unless only a so-called value-free or strict physiologic definition of futility is used; 4) the concept of futility is not practically useful because empirical treatment data cannot be applied with certainty to any given patient; 5) futility undermines our pluralistic society and threatens, among other things, the free exercise of religion; and 6) because cost considerations will ultimately dictate all such decisions, futility is an unnecessary concept.

Patients with chronic lung diseases suffer higher symptom burden, lower quality of life, and greater social isolation compared with patients with other diagnoses, such as cancer. These conditions may be alleviated by palliative care, yet palliative care is used less by patients with chronic lung disease compared with patients with cancer. Underuse is due, in part, to poor implementation of primary palliative care and inadequate referral to specialty palliative care. Lack of primary and specialty palliative care in patients with chronic lung disease falls short of the minimum standard of competent health care, and represents a disparity in health care and a social injustice. We invoke the ethical principles of justice and sufficiency to highlight the importance of this issue. We identify five barriers to implementing palliative care in patients with chronic lung disease: uncertainty in prognosis; lack of provider skill to engage in discussions about palliative care; fear of using opioids among patients with chronic lung disease; fear of diminishing hope; and perceived and implicit bias against patients with smoking-related lung diseases. We propose mechanisms for improving implementation of palliative care for patients with chronic lung disease with the goal of enhancing justice in health care.

Social isolation and loneliness are ongoing threats to health made worse by the coronavirus disease 2019 (COVID-19) pandemic. During the pandemic, half the globe's population have been placed under strict physical distancing orders and many long-term care facilities serving older adults went into lockdown mode, restricting access to all visitors, including family members. Before the pandemic emerged, a 2020 National Academy of Sciences, Engineering and Medicine report warned of the underappreciated adverse effects of social isolation and loneliness on health, especially among older populations. Social isolation and loneliness predict all-cause mortality at rates that rival clinical risk factors, such as obesity and smoking; they are associated with greater incidence of psychological, cognitive, and physical morbidities. This paper sets forth a proposal to design robots to function as companions and friends for socially isolated and lonely older people during pandemic emergencies and in aging societies more generally. "The proposal" section presents and defends the proposal. The "Replies to objections" section answers objections based on coercive design, replacement of humans with robots, privacy incursions, and counterfeit companionship. The "Conclusion" section submits that sociable robots offer a promising avenue for addressing social isolation and loneliness during pandemics and hold promise for aging societies more broadly.